Loss of Medicaid Coverage During the Renewal Process

This cohort study measures the proportion of people who lose Medicaid coverage at the renewal deadline, overall and by enrollee characteristics, and time until regaining Medicaid coverage among those losing coverage at the deadline.


Introduction
Each year, millions of individuals with low income must redemonstrate their eligibility for Medicaid to avoid losing benefits in a process that is called recertification, redetermination, or renewal. 1,2[5][6][7][8][9] Policymakers have raised concerns that administrative difficulties with renewal of coverage may prevent fair and equal access to benefits among all who are eligible. 10,11sing Medicaid coverage can result in a variety of adverse effects.9][20][21] Identifying factors associated with Medicaid coverage loss can inform efforts to help eligible beneficiaries keep their coverage; however, little is known about who typically loses eligibility for Medicaid during renewal.3][24][25] While states are required to publish statistics on how many people lose Medicaid during unwinding, these numbers lack historical comparisons.To inform policy discussions on how frequently Medicaid renewal should be required under "typical" conditions, [26][27][28] data are needed on who loses coverage during renewal.This cohort study measures losses of Medicaid coverage during annual renewal processes, including both potentially avoidable losses due to administrative requirements and those due to lack of eligibility.We used administrative data on the universe of nonelderly, nondisabled Wisconsin Medicaid (BadgerCare Plus) members before renewal requirements were suspended due to the COVID-19 public health emergency.The findings will inform policy by identifying groups of people with low rates of renewal who may benefit from targeted outreach and assistance, and by providing a historical benchmark to facilitate interpretation of data from the unwinding process.

Study Setting
We used data from Wisconsin.As in most states, beneficiaries must typically renew their eligibility for Medicaid 12 months after coverage begins (an exception is pregnant individuals, whose renewal date is 2 calendar months after the date their pregnancy ends).Early in their 11th month of Medicaid enrollment, beneficiaries are mailed notices stating that some or all of their benefits will end if renewal is not completed by the end of the following month. 29Renewals can be completed in person or via telephone, mail, or online.Coverage ceases if the beneficiary does not complete renewal by the deadline.Late renewals are possible for up to 90 days after the deadline; beneficiaries determined eligible during this period may have their coverage reinstated back to the termination date.People who lose Medicaid may reapply at any time.Thus, eligible people who lose Medicaid coverage may regain it quickly (sometimes called "churning"), whereas people who lose coverage due to ineligibility may remain without Medicaid for a longer period.This observational cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.The institutional review board at Texas A&M University determined that the analysis did not constitute human subject research and did not require further review.

Statistical Analysis
We used a nonparametric Kaplan-Meier analysis to visually compare rates of coverage loss at the renewal deadline (month 12) vs other months.We calculated rates of Medicaid coverage loss before and at the renewal deadline and duration of coverage loss among those who lost coverage at the renewal deadline, both overall and by enrollee characteristics.We also tested whether there was a statistically significant difference in coverage outcomes by enrollee characteristics using χ 2 tests.
Next, we used logistic regression to identify factors associated with coverage loss during renewal.The first regression model tested whether factors associated with eligibility for and use of Medicaid-covered health care were associated with coverage loss during the renewal process using an F test to assess the joint significance of these variables.The second regression model additionally included demographic characteristics.We tested whether demographic factors remained associated with coverage loss after adjustment for factors associated with eligibility for and use of Medicaid services by using an F test to assess the joint significance of demographic variables.We reported average marginal effects and robust standard errors for all logistic models.
Analyses were performed in Stata, version 18 (StataCorp).Two-sided hypothesis tests were conducted with P < .05 as the threshold for statistical significance.income less than 25% of FPL.Among sample members, 2% identified as American Indian or Alaska Native, 4% as Asian or Pacific Islander, 19% as Black, 12% as Hispanic, 4% as multiracial, and 51% as White, with 9% unknown.

JAMA Health Forum | Original Investigation
Figure 1 and Table 2 quantify the loss of Medicaid coverage before and after the renewal deadline for the full sample.Figure 1 presents a Kaplan-Meier curve capturing the duration of continuous Medicaid enrollment.Enrollment rates declined on a smooth path prior to the renewal deadline but then fell sharply, by 13 percentage points, at the deadline.Among people enrolled the month prior to the renewal deadline, 20% lost Medicaid coverage at the deadline.
Table 2 also summarizes coverage loss by enrollee characteristics.There were statistically significant differences in the rate of coverage loss at the renewal deadline by enrollee eligibility category and by age.For example, while childless adults and parents had the same rate of Medicaid coverage loss before the deadline (44% for both groups), childless adults were more than twice as likely as parents to lose coverage at the deadline (35% vs 15%, respectively).Furthermore, only 15% of children younger than 12 years lost coverage at the redetermination deadline, compared with 23% of older children.
Rates of coverage loss at renewal also varied by the amount of health care costs Medicaid paid during the enrollee's first 6 months of enrollment (Table 2).Among people enrolled just before the renewal deadline, 42% of those with no costs paid by Medicaid lost their coverage at the deadline, compared with 17% of people in the bottom quartile of health care costs and 6% of people in the top quartile.Indeed, for 64% of the people who lost coverage at the deadline, Medicaid had not paid any health care costs during their first 6 months of enrollment.In contrast, the differences in rates of coverage loss at renewal between income categories were very small, although statistically significant.respectively.There is no clear gradient in duration of coverage loss by income, but there is a clear negative association between duration of coverage loss and past health care costs.For example, more than 82% of people with health care costs in the top quartile regained coverage within 6 months, compared with only 21% of enrollees who had no health care costs.
Table 3 summarizes the factors associated with losing Medicaid at the renewal deadline among people who had Medicaid coverage just before the deadline.The results of the first model show that factors associated with eligibility for and use of Medicaid services-eligibility category, household income at enrollment, and health care costs during the first 6 months of enrollment-are jointly associated with risk of losing coverage at the deadline.In the adjusted data, children and parents were 18.9 (95% CI, −19.2 to −18.6) and 17.1 (95% CI, −17.5 to −16.8) percentage points less likely, respectively, to lose their coverage at the deadline than childless adults (P < .001for both).Income was also associated with coverage loss; people with a household income more than 75% of FPL at the time of enrollment were 4.9 (95% CI, 4.6-5.2) percentage points more likely than those with an income less than 25% of FPL to lose coverage at the deadline (P < .001).Finally, people with higher health care costs paid by Medicaid had a lower risk of losing coverage at the deadline, with the risk of coverage loss declining monotonically for each quartile of health care costs.People with costs in the highest quartile were 33.8 (95% CI, −34.1 to −33.5) percentage points less likely to lose coverage at the deadline than people with no health care costs (P < .001).
The second model in Table 3 tests whether personal characteristics were associated with coverage loss after adjustment for factors associated with eligibility for and use of Medicaid services.
Age, gender, race and ethnicity, education level, and metro area residence remained associated with the risk of losing Medicaid at the renewal deadline after adjustment for factors associated with eligibility for and use of Medicaid services.In the adjusted results, female enrollees were 0.5 (95% CI, 0.3-0.8)percentage points more likely to lose Medicaid at the deadline than male enrollees (P < .001).Compared with rates of coverage loss among non-Hispanic White enrollees, rates of loss at the deadline were 2.4 (95% CI, 1.2-3.7)percentage points higher among American Indian or Alaska Native enrollees (P < .001),4.3 (95% CI, −4.8 to −3.8) percentage points lower among Asian or Pacific Islander enrollees (P < .001),not significantly different among Black enrollees, 1.5 (95% CI, 1.2-1.9)percentage points higher among Hispanic enrollees (P < .001),not significantly different among multiracial enrollees, and 4.7 (95% CI, −5.1 to −4.3) percentage points lower among those with unknown race (P < .001).

Discussion
In this study of Medicaid beneficiaries with a renewal deadline 12 months after enrollment, 1 in 5 enrollees lost coverage at the renewal deadline.Among this group, 37% regained coverage within 6 months, whereas 53% remained without Medicaid coverage for at least 12 months.These lapses health emergency, when people may have been unaware that their Medicaid coverage had been extended, 30 the proportion of people who rarely used their coverage may have been even higher.
In the present data, children younger than 12 years were the eligibility group most likely to regain Medicaid coverage quickly if they lost it, with half regaining coverage within 6 months.The consequences of short-term disruptions in Medicaid coverage include interrupted access to needed care 31,32 and administrative costs for the Medicaid program of up to $500 each time an enrollee loses and regains Medicaid. 33,34If a rapid return to Medicaid coverage suggests that the enrollee lost coverage due to difficulties with the renewal process rather than because of ineligibility, then

Strengths and Limitations
This analysis has several strengths.Importantly, we were able to isolate individuals who had Medicaid coverage just before the renewal deadline.Thus, the association between Medicaid-covered costs and the likelihood of losing coverage at renewal cannot be attributed to reverse causality (ie, people had no health care charges paid by Medicaid because they lost Medicaid coverage).The analysis also has important limitations.The sample does not include people who were originally eligible for Medicaid due to pregnancy or disability, and the effects of renewal requirements may differ for these groups.Furthermore, we cannot observe whether an enrollee took action to renew their coverage, including late renewals (which, if successful, would result in no loss of coverage).The data reflect the experiences of all beneficiaries, including those whose renewal was processed automatically (ex parte).Wisconsin uses ex parte renewals for less than half of its Medicaid population. 35Because ex parte renewal processes can increase rates of renewal, [36][37][38][39] the results may not reflect the experience of states that certify eligibility of most enrollees on an ex parte basis.Finally, Wisconsin operates a joint Children's Health Insurance Program-Medicaid program; churn between these programs may be relevant to beneficiaries in other states.

Figure 2 Figure 1 .
Figure 2 categorically depicts the duration of Medicaid coverage loss among those who lost coverage at the renewal deadline, overall and by enrollee characteristics (eFigure in Supplement 1 shows overall duration continuously).Overall, 37% of enrollees who lost coverage at the deadline regained Medicaid coverage within 6 months, and an additional 10% regained coverage between 6 and 12 months; the other 53% remained without Medicaid coverage for at least 12 months, as seen in Figure 2A. Figure 2A also depicts variations in the duration of coverage loss by age and eligibility category.While 64% of childless adults who lost Medicaid at the deadline remained without Medicaid for at least 12 months, children younger than 12 years often reenrolled quickly, with 51% regaining coverage within 6 months.Figures 2B and C show the duration of Medicaid coverage loss

Figure 2 .
Figure 2. Duration of Coverage Gap for Enrollees Who Lost Coverage at Renewal Deadline by Enrollee Characteristics administrative barriers may account for a larger share of coverage losses among children than among other groups.Future research should consider the benefits and costs of making renewal requirements less frequent and how long to guarantee continuous coverage.The 2023 Consolidated Appropriations Act requires states to provide 12 months of continuous enrollment for children beginning in January 2024.27

JAMA Health Forum | Original Investigation
The analysis used administrative data from Wisconsin, including Medicaid enrollment, claims, and encounter data.The study sample included 751 110 new enrollment spells for nonelderly (aged <65 years), nondisabled individuals in Wisconsin Medicaid at any point from January 2016 through January 2018.Individuals were followed up through January 2020 to provide at least 24 months of data prior to the implementation of the Medicaid continuous coverage policy.Data were analyzed from August 2023 to February 2024.A new spell was defined as enrollment following a Medicaid coverage gap of 1 or more months, which would begin a new 12-month renewal period.We excluded spells that began because of pregnancy or foster care-related Medicaid eligibility (n = 39 199) JAMA Health Forum.2024;5(5):e240839.doi:10.1001/jamahealthforum.2024.0839(Reprinted) May 3, 2024 2/12 Downloaded from jamanetwork.comby guest on 05/05/2024

Table 1 .
Loss of Medicaid Coverage During the Renewal ProcessThe study sample included 684 245 Medicaid enrollment spells from 586 044 people; 51% of sample members were female, and 47% were children 18 years or younger.Table1summarizes the characteristics of people in the study sample, both overall and by major eligibility group (childless adult, parent/caretaker, or child).Most sample members lived in metro areas (71%), and 47% had an Characteristics of People in the Study Sample by Eligibility Category JAMA Health Forum.2024;5(5):e240839.doi:10.1001/jamahealthforum.2024.0839(Reprinted)May3,2024 3/12 Downloaded from jamanetwork.combyguest on 05/05/2024Resultsa Defined as age 18 years or younger.bGender and race and ethnicity were generally self-identified but were occasionally reported by caseworkers.

Table 2 .
Loss of Medicaid Coverage Before and at the Renewal Deadline by Enrollee Characteristics Abbreviation: NA, not applicable.aχ 2 Test of joint significance.bGenderandrace and ethnicity were generally self-identified but were occasionally reported by caseworkers.JAMA Health Forum | Original InvestigationLoss of Medicaid Coverage During the Renewal Process JAMA Health Forum.2024;5(5):e240839.doi:10.1001/jamahealthforum.2024.0839(Reprinted) May 3, 2024 6/12 Downloaded from jamanetwork.comby guest on 05/05/2024 by income category and health care costs during the first 6 months of Medicaid enrollment,

Table 3 .
Factors Associated With Losing Medicaid Coverage at Renewal Deadline by Logistic Regression Model a both potentially avoidable coverage losses due to administrative burdens and coverage losses due to ineligibility.These data describe which groups most frequently lose access to Medicaid at the renewal deadline and regain Medicaid coverage in the months after the deadline.When people in households with very low incomes (FPL <25%) lost Medicaid coverage at renewal, they did not regain coverage faster than their counterparts with higher income.Furthermore, the risk of Medicaid coverage loss varied by demographic factors even after adjustment for factors relevant to eligibility for and use of Medicaid services, with female enrollees, Hispanic enrollees, and Native American or Alaska Native enrollees showing elevated rates of coverage loss at renewal.People with considerable health care needs may be more motivated to complete renewal processes, and the individuals or organizations providing their health care may be motivated to assist them.Past use of health care paid by Medicaid was strongly associated with loss of Medicaid coverage at renewal; in adjusted models, people in the highest quartile of health care use were 34 percentage points less likely to lose coverage at redetermination than people who used no health care.If people with no Medicaid-covered costs were removed from the sample, the risk of Medicaid loss at renewal would decline by half, to only 11%.In the present sample, more than half of enrollment spells had no Medicaid-paid health care costs during the first 6 months.During the COVID-19 public a The table reports the average marginal effects from logistic regression analyses of the probability of coverage loss during the Medicaid renewal process.Omitted categories are as follows: people eligible for Medicaid in the childless adult eligibility category, no health care spending during the first 6 months of coverage, income less than 25% of the federal poverty level, age younger than 30 years, male gender, less than high school or missing education, non-Hispanic White race, location of residence in a metro area, not a US citizen, and not a tribal member.bF test of joint significance.include